Tuesday, October 23, 2012

Thursday 4:30-6:30 pm Book Signing at B&N at the Inner Harbor PowerPlant

I will be at the Barnes and Nobel bookstore in the Inner Harbor Power Plant this Thursday from 4:30 to 6:30pm. Please do stop by and say Hello.

I will be happy to sign your copy of "The Future of Health Care Delivery - Why It Must Change and How It Will Affect You."


Saturday, October 20, 2012

Will Eating Chocolate Increase Your Chances For A Nobel Prize?

We all want to not only improve or cognitive function but to preserve it as we age. Certain dietary flavonoids improve cognition and these can be found in foods like cocoa, green tea and red wine.
Franz Messerli, MD, a self-described lover of dark chocolate published an article in the New England Journal of Medicine October 10, 2012 on the implied potential of chocolate in improving cognitive function. He hypothesized that one might use the awarding of Nobel prizes as a surrogate for superior cognition. He thus rank ordered countries by the per capita number of Nobel laureates through October, 2011. He then obtained chocolate consumption per capita for 22 countries. He found a close linear correlation which was highly statistically significant between chocolate consumption and the awarding of Nobel prizes.


Messerli points out that the chocolate consumption of individual Nobel laureates is not known and that “the cumulative dose of chocolate that is needed to sufficiently increase the odds of being asked to travel to Stockholm is uncertain.”  And of course he notes that this correlation is in no way proof of cause and effect. But it does offer one more satisfying rationale for chocolate cravers to persist in their love affair.

Wednesday, October 17, 2012

Paying Primary Care Physicians Directly is Advantageous

I wrote an Op Ed for the Washington Times that ran today suggesting it is advantageous to us as patients when we pay our primary care doctors directly rather than depend on insurance. This returns us to the position of being in a direct professional financial contractural relationship with our PCP. It leads to better care, greater satisfaction and ultimately a major reduction in total health care expenses.

Here is the link

Wednesday, October 10, 2012

Transformational and Disruptive Changes Are Coming to the Delivery System

More chronic illnesses, more diseases of old age, consumers demanding more quality and safety, physicians no longer in typical private practice, and high deductible health care polices are each about to cause major changes in the practice of medicine and how it is delivered to patients. Will this come about smoothly or, more likely, with some serious hand wringing? 

Health care delivery will change substantially in the coming years. This is not because of reform but rather due to a set of drivers that are exerting a great push and pull to the delivery system. Some of these changes will be quite transformational and some will be very disruptive of the status quo. What are these drivers?
One of the most important is that there will be many more individuals with chronic illness. The Milliken Institute offered a white paper a few years ago on chronic illnesses and noted that nearly one half of Americans had one or more chronic illnesses, most of them preventable and  which were costing the economy over $1 trillion per year and rapidly rising.  

These are diseases like diabetes with complications, heart failure, cancer, or chronic lung disease. What is apparent is that they are mostly due to adverse lifestyles. Eating a non-nutritious diet -- and too much of it combined with a sedentary existence leads to obesity. One third of Americans are overweight and another one third are frankly obese. Add to this chronic stress and that 20% still smoke and there is an effective recipe to produce chronic illnesses. Chronic illnesses will make up a greater and greater proportion of all medical ailments as time goes on. And of course they are more difficult to manage, generally last a lifetime and are inherently expensive to treat (although there is much that can be done to reduce the costs of care.) 

A second driver of change is the aging of the population. The American society is growing older and just like a car:  “Old parts wear out.” Aging brings on visual and hearing impairments, mobility difficulties and diseases like osteoarthritis, Alzheimer’s and other chronic illnesses that, as best we know today, are not due to adverse lifestyles but are tied into the aging process. 

Another driver is the increasing demand for medical services. Perhaps this is saying the same thing another way. More aging and adverse lifestyles create more disease and the need for care. 

Consumerism is becoming – finally – more and more of a driver of change. Patients are coming to want and expect to be treated like a valued customer. Like the movie where he shouted “I can’t take it any more,” now “the patient is no longer willing to be patient any more.” What do the patients want? They want service, good service. They increasingly understand that quality and safety are not ideal so they are looking for and expecting high levels of quality & safety. Perhaps the most important one of all is respect, respect for their person, confidentially, and the quality of their care. But also patients want convenience & responsiveness. They don’t want to have to travel long distances, wait long times in the “waiting room,” nor be put on indefinite telephone hold. They want interaction by email and other electronic methods.   And finally, patients increasingly expect to have a closing of the information gap – they expect the playing field between patient and doctor to be much more level in the future. 

Professional shortages are also definite drivers of change in the delivery system. There have been shortages of nurse and pharmacists noted for more than a decade. More and more there is a shortage of primary care physicians (PCPs) and also general surgeons. These shortages are more acute in rural areas and urban poor areas.

Combined with shortages are changes in professional aspirations and lifestyles. More and more physicians want and expect to have more time for family and recreation. And they no longer want to run their own private practices. They prefer to be employed with little if any administrative burdens. Indeed the number of PCPs in a typical private practice arrangement has declined precipitously in recent years. And since so many patients coming to the ER today are uninsured, many physicians are no longer willing to take call unless on a contract with the hospital. Most physicians are willing to accept that some patients will be of limited means but they are not wiling to be overwhelmed with non paying patients.  

And among many other drivers of change is that patients will have greater requirements toward a direct share of costs. Today we have mostly “prepaid” health care, meaning that our insurance covers most everything, minus a low deductible or co-pay, from routine exams and well baby care all the way to a heart transplant. Among employer sponsored plans, there is an increasing push toward high deductible plans, with deductibles in the $1000-2000 range. Even some Medigap plans have high deductibles corresponding with much lower premiums.  

These are but a few of the drivers that will change the delivery of health care in dramatic ways in the years ahead. I discuss them in much more detail in The Future of Health Care Delivery – Why It Must Change and How It Will Affect You with data obtained through over 150 in-depth interviews of medical leaders from across the country. It is fair to expect that physicians, patients, hospitals, insurers and employer/government sponsors will be challenged to adapt.

My next post will examine what these drivers of change will actually cause to happen to the delivery system.

Monday, October 1, 2012

You Are Not Your Doctor’s Customer - But You Can Do Something About It

Our care is generally good in the United States but not as good as it could be nor as good as it should be. There are multiple problems to consider.  

First, ours is a medical care system not a health care system. We focus on disease once it has occurred but give relatively little attention to maintaining health and developing wellness.  

Clearly there is a need for greater attention to disease prevention and health promotion.  Second, our sytem developed over many decades to care for acute illness but today we are faced with more and more chronic diseases. Sure there are still patients with an ear infection or a broken leg. But more and more individuals are developing diabetes, heart failure (both of these now becoming epidemics), cancer, chronic lung disease and others. These are illnesses that generally last a lifetime (some cancers can be cured, of course), are complex to manage and inherently expensive to treat. They are best handled by a multi-disciplinary team coordinated by a primary care physician. But such is seldom the case today.  

Third, of course, many do not have health insurance with some 47 million uninsured and many more underinsured. And as they obtain insurance or join the Medicaid ranks as the result of healthcare reform, there will be way too few primary care physicians to care for them. They will therefore continue to use the emergency room as their principle place for care.

Fourth, our system of care is not customer-focused. We wait long weeks and months for an appointment, spend long times in the waiting room and are frustrated that we get just 12-15 minutes with our doctor. Our doctor suggests that we go to a specialist but does not personally call the specialist to explain the issue nor to smooth the path for a speedy appointment. 

And then there are the insurers. We are not their customer – our employer is their customer or our government is their customer but not us. And it shows – by our long waits on the phone, by the complex often hard to understand paperwork and by the frustration when the insurance we thought we had does not cover our latest tests, x-rays or specialist visit.

Indeed we are not the insurer’s customer nor are we the doctor’s customer. The physician is the customer – sort of – of the insurance company. We are mere bystanders. This is hardly the type of contractual relationship we have with our lawyer, architect or accountant. 

So a new vision for our system must make it a healthcare not just a medical care system. It must recognize the importance of intensive preventive care to maintain wellness. It must address the needs of those with chronic illnesses (who consume 70-85% of all healthcare claims paid) to both improve quality of care while dramatically reducing the costs of care. And it must be redesigned so that the patient is the customer that he or she should be – of both the physician and the insurer. It’s doable but it means a rethinking of how our delivery system is structured. 

One thing individuals can do now is to obtain a high deductible insurance policy. This means your premiums will come down and you will be paying for primary care out of pocket. But primary care is generally not expensive and now you will be in a position to expect more from your doctor – after all, it is you who is paying the bill and doing so directly. Alternatively, look for a PCP that has a retainer based practice or simply does not accept insurance. In each of these scenarios, you now have a direct professional contractual relationship with your doctor. You will be treated as such and now you are more likely to challenge suggestions and ask questions. You will also get better preventive care because the doctor has more time to spend with you. The result will be far fewer referrals to specialists, fewer tests and procedures and an ultimate savings in health care costs.

Sunday, September 23, 2012

America Has a Medical Care System Not a Health Care System

As Americans we believe we have the best healthcare system in the world. But think again, it’s really not the truth. Health care delivery is dysfunctional. 

We do have superb medical schools, very well trained providers, superb science and technology but the delivery of medical care is just not what it should be. We spend more for healthcare than any other country does on a per capita basis. And yet when we compare ourselves to other countries, especially developed countries, our outcomes are not better.  

Our life spans are somewhat shorter than countries such as Japan and our infant mortality is somewhat higher than countries like England and France. We tend to focus on disease and injury but not so much on illness prevention and health promotion. We all recognize that as a society we have some adverse lifestyle behaviors such as overeating a non-nutritious diet, being fairly sedentary, having chronic stress and having 20% of us still smoking. It’s quite clear that the best chance we have for increasing our life span and overall improving our health is to adjust our personal behaviors and to do so at an early age. 

We often think of heart disease, cancer and stroke as the major causes of death and, as diseases that cause death, which is correct. But what if we go back further and look at what caused those diseases. The rank order of causes of death according to a study from the Centers for Disease Control in the Journal of the American Medical Association lists tobacco, poor nutrition, lack of exercise, alcohol to excess, infections, toxic agents, motor vehicle accidents, sexual behaviors and illicit drug use as the primary predisposing factors to the diseases that cause death. A look at that list shows that the ones at the top of the list and a number of others all relate to our behaviors.   

The diseases that occur have changed substantially over the decades. At the beginning of the 1900’s it was infectious diseases that caused most deaths. Over time they came under reasonably good control with preventive techniques such as immunizations, sanitary sewer systems and clean water systems and then, of course, antibiotics. Meanwhile chronic illnesses such as coronary artery disease became much more prevalent. Even though fewer people smoke than a few decades ago our obesity and our lack of exercise have led to rapid increases in diabetes, heart disease, stroke, high blood pressure and many other chronic illnesses that last a lifetime. Insurers note that it is these diseases that account for about 70-85% of claims paid.  

Our medical care system does not deal with health; it really concentrates on illnesses or trauma. It is a “sick-care” delivery system. In addition more and more illnesses today are chronic and complex, lasting a patient’s lifetime and bearing very high costs. The best way to care for these chronic illnesses is with a multi-disciplinary team approach. This is just not the typical way our medical care delivery system is organized. We tend to have a system that relies on a single provider treating an illness – the internist gives an antibiotic for pneumonia and the surgeon cuts out the diseased gall bladder. But patients with chronic illnesses really need multiple providers. For example, the diabetic may need in addition to a primary care physician, an endocrinologist, an exercise physiologist, a nutritionist, an ophthalmologist, a vascular surgeon, a nephrologist, etc. But to work well, this team needs a coordinator or quarterback and this is preferably the primary care physician. Good care coordination can direct the patient to the care he or she needs while reducing the number of specialist visits, procedures, tests and imaging -- with the result that the quality of care goes up and the cost of care goes down substantially. Unfortunately, PCPs who are mostly working in a non-sustainable business model have all too little time to give this needed care coordination; that is a topic for a later post. 

So we have a medical care system not a healthcare system. What we need in America today is a focus on health care meaning a greater focus on disease prevention and health promotion beginning in childhood and a recognition that chronic illnesses are the ones that not only last a lifetime but are also the diseases that are driving the high cost of care. These costs can be brought down and can be brought down quite substantially through a better approach to patient care, one that coordinates the care intensively while using a multidisciplinary team approach.  

America needs to shift from a medical care to a health care system that focuses on health and wellness and for those with chronic illnesses cares for them with a well-coordinated multi-disciplinary team. The result would be greater satisfaction for patients and providers alike, higher quality and lower costs.


Tuesday, September 18, 2012

America Has A Health Care Paradox

We have a real paradox in American healthcare. On the one hand we have exceptionally well educated and well trained providers who are committed to our care. We are the envy of the world for our biomedical research prowess, funded largely by the National Institutes of Health and conducted across the county in universities and medical schools. The pharmaceutical industry continuously brings forth life saving and disease altering medications. The medical device industry is incredibly innovative and entrepreneurial.  The makers of diagnostic equipment such as CAT scans and hand held ultrasounds are equally productive.   

A few examples.  The science of genomics is revolutionizing medical care in profound ways such as producing targeted cancer drugs, predicting later onset of cardiac disease, offering prognostic data to guide cancer treatment, rapidly identifying a bacteria and its antibiotic susceptibility and suggesting how our diet can actually impact our genes through the science of nutragenomics.   

The pharmaceutical industry has brought us the likes of statins to reduce cholesterol, drugs to prevent blood clotting, and the targeted therapies for cancer. The device industry has created, for example, a potpourri of new approaches that have transformed cardiac care. These include angioplasty, stents, pacemakers, intracardiac defibrillators and now even the ability to insert a prosthetic aortic valve through a catheter rather than doing it via open surgery.  And we can now noninvasively image organs in incredible detail and learn about physiology with molecular imaging. 

So we can be appropriately awed and proud and pleased at what is available when needed for our care.

But, on the other hand, we have a dysfunctional health care delivery system where quality is inadequate, costs are too high, outcomes are subpar and no one is the customer. 

Our current delivery system focuses on acute medical problems where it is reasonably effective. But it works poorly for most chronic medical illnesses and it costs far too much. When the famous bank robber, Willie Sutton, was asked why he robbed banks he replied “that’s where the money is.” In healthcare the money is in chronic illnesses – diabetes with complications, cardiac diseases such as heart failure, cancer and neurologic diseases. These consume about 75-85% of all dollars spent on medical care. So we need to focus there.

These chronic illnesses are increasing in frequency at a very rapid rate. They are largely (although certainly not totally) preventable. Overeating a non-nutritious diet, lack of exercise, chronic stress, and 20% still smoking are the major predisposing causes of these chronic illnesses. Obesity is now a true epidemic with one-third of us overweight and one-third of us frankly obese. The result is high blood pressure, high cholesterol, elevated blood glucose, etc., leading to diabetes, heart disease, stroke, chronic lung and kidney disease and cancer. 

And once any of these chronic diseases develops, it usually persists for life (of course some cancers are curable but not so diabetes or heart failure). These are complex diseases to manage and expensive to treat – an expense that continues for the rest of the person’s life. 

What is needed is aggressive preventive approaches and, for those with a chronic illness, a multi-disciplinary approach, one that has a committed physician coordinator. Providers (and I refer here mostly to primary care physicians), unfortunately, do not give really adequate preventive care in most cases. And they generally do not spend the time needed to coordinate the care of those with chronic illness – which is absolutely essential to assure good quality at a reasonable cost. 

When a patient is sent for extra tests, imaging or specialists visits the costs go up exponentially and the quality does not rise with the costs. Indeed it often falls. But primary care physicians are in a non-sustainable business model with today’s reimbursement systems so they find they just do no have enough time for care coordination or more than the basics of preventive care. 

So our paradox is that we have the providers, the science, the drugs, the diagnostics and devices that we need for patient care. But we have a new type of disease – complex, chronic illness, mostly preventable, for which we have not established good methods of prevention nor do we care for them adequately once the diseases develop. And all of this is exacerbated by an insurance system that puts the incentives in the wrong places. The result is a sicker population, episodic care and expenses that are far greater than necessary.  

This paradox, the dichotomy of excellent providers and science yet a dysfunctional delivery system, is at the root of today’s cost and quality crisis in medicine. It is amazing that Americans tolerate it.

Tuesday, August 28, 2012

Medical Megatrends Stem Cells – Part III

A cure for spinal cord injury? Diabetes? Macular degeneration?  Hope or just hype?

There are now some clinical trials using embryonic stem cells to treat serious diseases for which no other good therapy is currently available. But this is just the beginning of a major medical megatrend that will blossom forth in the coming years.

Embryonic stem cells are present after a fertilized egg divides for two or three days. They have the seemingly miraculous ability to turn into any of the tissue types in the body—whether brain neurons, beating heart cells, bone, or pancreatic islet cells. It is important to understand just where these cells come from. Those used in science are the byproduct of in vitro fertilization (IVF), cells taken from the often “left over” embryos that are otherwise discarded.

In 1998, scientists under the leadership of Dr James Thomson at the University of Wisconsin, learned how to take some of the cells from these about to be discarded embryos and put them into a cell culture – basically a fluid in which the cells can grow to produce more cells. These cells in turn can then be directed to grow into heart or lung or pancreas or other types of cells by the addition of various additives to the fluid in which they are growing. So it is from these discards that embryonic stem cells are available to us. Just to be clear. The blastocyst or embryo with its 32 or so cells is not grown in the culture dish. Rather, individual cells are removed and allowed to divide and grow. These are the so called embryonic stem cells. But no embryo is growing, just individual cells.

It is true that much can be done with adult stem cells as discussed last time but science so far suggests that embryonic stem cells hold promise for much more benefit. It will probably be embryonic stem cells (or perhaps induced pluipotent stem cells – see the first in this series) that pave the way for replacing the islet cells of the pancreas with new insulin producing cells to cure diabetes or replace the damaged cells in the brain that are key to Parkinson’s disease. Some strongly feel that it is wrong to use cells from embryos. It is important to remember that these are fertilized eggs that were prepared for couples that could not conceive and so had eggs and sperm placed into a dish with special fluids. Experience has shown that success is better if the doctor implants a few embryos into the woman’s uterus rather than just one. But the doctor may have more than enough embryos and the extras will be discarded if the woman becomes pregnant. I look at it this way. Since the embryos will be destroyed anyway, why not use them for creating stem cells that perhaps many people with diverse diseases might benefit from. It is not dissimilar to transplanting the organs of a person who has died in a car accident rather than burying them in the grave. And the embryo, made up of just a few cells, is disrupted so each cell grows independently. Now the cells can be stimulated to become heart cells, liver cells or whatever and might be useful in treating a disease. It will take some years but there will certainly be major advances down the road in how we can repair, restore or replace damaged tissues or organs.

The pace at which we benefit from stem cell therapy will be influenced by factors including cultural attitudes which in turn lead to legislative decisions and legal challanges. The issues revolving around federal funding via the NIH for research on embryonic stem cells reached the federal courts two summers ago and were further addressed by an appellate court in April of 2011. Cohen and Adashi, writing in the New England Journal of Medicine in May, 2011, gave a clear account of the debate in the courts. They concluded with “It is difficult to overestimate the vast potential of stem-cell research. We believe we cannot afford to allow ongoing legal ambiguities to compromise this line of scientific pursuit. Quite the contrary, now is the time to pick up the pace with an eye toward realizing the hoped-for translational benefits. With statutory relief deemed unlikely to be provided before the 2012 elections, it appears all but inevitable that the matter of funding of human ESC research will have to be settled in a court of law.” Of course that never happened and stem cell research is not high on the public’s set of concerns for this year’s elections but the makeup of the coming Congress after the election could be relevant down the road.

Here is an example of how stem cells could be used: islet cells on demand– One day, and I believe it will occur within five to ten years, stem cells will be able to be mass grown into islet cells. They will be ready when the patient needs them. Just give them by vein and they will home into where they need to go.  And if they are created from the process called nuclear transfer or adult cells reprogrammed from the patient by genes (iPSC) or proteins (piPSC) that I described previously, they probably will not be rejected because they will be developed to not provoke the immune system. But still, whatever process destroyed their own islet cells years before will probably still be functional. So these new cells may be destroyed over time as well, unless some new technology or drugs are developed to prevent this cell destruction by the body. But in the meantime, just come back for a new infusion whenever needed. Sort of like going to the gas station to refill the tank!

Islet cells injected into the vein seem to know to go to the liver and live there and do their work. Bone marrow stem cells when injected by vein go to the bone marrow, take up residence and repopulate the marrow of the patient with leukemia who just got very aggressive treatments to eliminate all of his own marrow cells (and hopefully all of the leukemia cells as well.) But would all stem cells know where to go? Or what to do? Would they go to the heart after a heart attack or do they need to be infused directly into the coronary arteries or injected into the heart muscle itself? And stem cells or stem cells prompted to develop into brain cells – will they need to be injected directly into those areas of the brain damaged by Parkinson’s or Alzheimer’s diseases? These are but a few of the issues to be resolved with careful research.

Here are just a few studies in progress, some in animals, some in humans and many in laboratory settings:

                        iPS cells have been created for multiple different diseases by taking cells from affected patients  such as diabetes type I, Lou Gehrig’s disease (amyotrophic lateral sclerosis), Gaucher’s disease  and muscular dystrophy. It is hoped that these cells will help explain the disease processes and their origination. In addition, they might prove useful in growing large numbers of mature cells that could in turn be used for drug screening and drug toxicity evaluations. And in this regard, iPSCs and piPSCs matured into cardiac cells are already being used by pharmaceutical companies to test new drugs for side effects.

We all know that if we have a tooth pulled, that’s it – a tooth won’t grow back. But an intriguing study has taken the cells of the progenitors of the molars from mouse embryos and grown them in culture for a few days. Meanwhile, a molar or two from multiple adult mice were extracted. Then the stem cells were implanted into that space and within two months the mice had new teeth with normal structure and strength, demonstrating that stem cells in the proper setting can lead to the re-growth of an organ or tissue. Think about the potential in humans to get a real new tooth rather than a prosthetic tooth or a bridge when a diseased or damaged tooth must be extracted.

One of the most exciting studies to get underway was a phase 1 trial of stem cells in patients with spinal cord damage. The Geron Company began this FDA-approved trial in late 2010. They took human embryonic stem cells and from them derived oligodendrocyte progenitor cells; in other words, nerve cells. These were injected next to the spinal cord at the level of very recent injury. In extensive animal experiments, these cells were found able to cause the damaged spinal cord cells to remylinate (basically reapply an “insulator” as with the covering of an electric wire) and to create some type of nerve growth stimulation with remarkable restoration of some or all function. The rats began to move much more normally within just a week or so of the injection. Then came the human trial. It was Phase 1 meaning that it was all about studying if the injected cells would cause any toxicity. It is a good guess that they would not but because they were be used initially in low dosage (relative to what was used in the rats to obtain responses) so it is unlikely any functional improvement would occur. That would be the test in later trials (Phase 2 and 3) with higher cell numbers provided this Phase 1 study proceeded successfully. As it turned out, Geron Corporation ended the study after enrolling just four patients citing lack of adequate funding to continue. This left Advanced Cell Technology, Inc. as the only other American company conducting a study of embryonic stem cells – for macular degeneration and for macular dystrophy in the eyes. They use embryonic stem cells to produce retinal epithelial pigment cells to be injected behind the retina in affected patients. Results will be forthcoming.

Another very early Phase I study, this one using adult stem cells, is just beginning in Israel for amyotrophic lateral sclerosis (ALS). The patient’s own bone marrow stem cells will be treated in the laboratory with a proprietary process by BrainStorm Cell Therapeutics and then placed back into patients. So far 12 of 24 patients have been treated with no apparent adverse effects. The final results will be of real interest.

As I said at the beginning, there is still much to be learned before stem cells will become routinely utilized for patient care – but progress is real and the opportunities are exciting for a major transformation of medical care in the coming years. It is becoming more hope than hype. Here, as with genomics, we see the value and the importance of innovation. Scientists with good ideas taking the steps needed to bring new and until recently almost undreamed of possibilities to transform healthcare – clearly a medical megatrend in the making.

Saturday, July 28, 2012

Medical Megatrends – Stem Cells – Part II of III

Imagine a man with a recent severe heart attack who has the muscle repaired with stem cells or a child with a severe bladder defect repaired with stem cells grown on a biodegradable scaffold. Sounds like science fiction but these are actual clinical studies in progress today.
Stem cell therapies promise to be one of those scientific breakthroughs that will have an enormous impact on health care in the future. Stem cells will bring us closer to the goal of personalized medicine, just as genomics is doing. The course of a disease will change once we have the technology to develop and then insert stem cells into the human body to actually create a tissue. For example, a person with a heart attack will not go on to live the rest of his or her life with damaged heart muscle and resultant heart failure. Instead, stem cells will repopulate the heart muscle and make it whole again. Similarly, a person with Parkinson’s disease will recover full faculties thanks to the ability of stem cells to regenerate the damaged area of the brain. The person with type I diabetes will be free of the disease because of the formation of new pancreatic islet cells. The athlete will play again because new cartilage will be created for the worn knee. This is the promise of “regenerative medicine.” I have written the above as though each will definitely happen, a promise that will be kept. They probably will, but it may be a long time before the science of stem cells is sufficiently developed that these types of incredible results will be commonplace.
            Adult stem cells are being used today for treatment of a few diseases and there are studies ongoing and planned for many additional possibilities. Let’s consider a few of them. Each of our tissues has a population of cells that can divide as needed to keep the organ or tissue functional as cells die or are injured. We see this with our skin as it constantly lays down new cells which make their way to the surface as the dead cells on the surface are rubbed off in the shower. We also see it when we cut ourselves and yet in a few days the wound is completely healed – that was stem cells at work. It appears that essentially every organ has its own pool of such cells. There are cells in the bone marrow that can become stem cells for many different tissues. These cells circulate in the blood and can be called to assist a tissue or organ to rebuild itself after injury or damage. So for example, if a surgeon takes one half of a father’s liver for transplantation into his son, we know that the father’s liver will grow back to normal size within about 6 to 8 weeks. Some of the stem cells will have been those already in the liver but some will have come from the blood stream to assist. Of course, the liver is the exception to the rule that if a portion of an organ is removed by trauma or surgery, it will not grow back. Cut off your finger and stem cells will help it to heal but not to grow back to its original state. 
            Adult stem cells are the ones used for treating leukemia, myeloma and other cancers and for correcting certain childhood immune deficiencies. Most often is the use of allogeneic hematopoietic stem cell transplantation, meaning the use of stem cells obtained from a closely matched individual. An identical twin is ideal but few have such a potential donor. Only 25% of siblings will likely match completely. This leaves the use of the National Marrow Donor Registry to find as close a match as possible from unrelated individuals. The Registry has markedly improved the chances for a close match and thus for successful transplantation outcomes. Many parents are now having umbilical cord blood saved and frozen to have available in the unlikely event that their child requires a transplant many years later. Although these cells are identical they usually are not sufficient in numbers to lead to engraftment and often the white blood cells (neutrophils) recover only very slowly leaving a prolonged period of infection risk. Perhaps a technique will be found to get the umbilical stem cells to multiply in the laboratory so that a larger number would be available.
                        Adult stem cells are being used in studies of myocardial infarction and heart failure. Current guidelines of immediate angioplasty and stent insertion as appropriate help protect the heart from permanent damage after an infarct. Still, about 400,000 new cases of heart failure are developing in the USA each year. Long term survival is limited once overt failure develops. Could the damaged heart muscle be fixed? The concept is to use stem cells to repopulate the muscle fibers and to have those cells divide over and over and differentiate into new muscle fibers or perhaps also the small vessels that carry blood to the muscle cells.  So far there are some exciting animal studies and even some trials in patients that are encouraging enough to warrant further evaluations. For example, one study uses adult mesenchymal stem cells derived from the bone marrow and infused intravenously within 7 days after a heart attack. 42 centers are collaborating in this double blind, randomized trail in conjunction with Osiris Therapeutics. 220 patients will receive either the stem cells or a placebo and then be monitored with various imaging and functional studies.  So, stay tuned.
            Another common albeit less lethal problem is loss of bladder control leading to incontinence. There are studies in progress to determine if stem cells placed into the bladder’s sphincter muscle will help it regain control. The adult stem cells are obtained from a leg muscle biopsy. Stem cells are isolated and allowed to grow in tissue culture. These are then injected into the weakened bladder sphincter muscle. Once again, these are studies just beginning but with intriguing early results.
            Here is another bladder repair concept. When the bladder muscle is weak or largely missing in children it may be possible to literally rebuild the bladder by tissue engineering. A biopsy of the bladder yields cells that can be grown in the laboratory to large numbers. They can then be placed on a biodegradable scaffold and grown further. In time they seem to create a new bladder muscle wall complete with blood vessels. This layer of cells can be implanted in the bladder of children with a defect. Once more I need to note that it is still early days in these studies but they do raise exciting possibilities.
            The message here is that adult stem cells are being used today for life threatening and life impairing diseases with excellent success and are being studied in other diseases with exciting prospects for the future.

Saturday, July 21, 2012

Medical Megatrends – Stems Cells – Part I of III

             New cells to replace those destroyed in diabetes type 1, cells to help heal a heart attack, cells to cure leukemia – this is the promise of stem cells. Some of this is happening now; more will be available in a few years.
Stem cells will usher in the era of regenerative medicine, allowing the creation of cells, tissues and organs to treat or cure diseases and injuries. This will be a fundamental alteration in our approach to medical care and a transformational medical megatrend. And it will be very “personalized medicine” to provide the specific individual with custom tailored new cells and tissues for organ repair or replacement.
Extensive use of stem cells as therapy is still in its infancy. Call it infancy  because  there is so much basic science still to be understood, that it will be quite some years before we will see stem cells being used on any sort of regular basis to treat diabetes, Parkinson’s disease, or heart failure after a heart attack. But time flies, many investigators are hard at work and the science may advance quickly.
There are exceptions; stem cells are being actively used for a few situations and have been for many years. Among them are “bone marrow” or stem cell transplantation for diseases like leukemia, some cancers being treated with very high doses of chemotherapy or some individuals, especially children, with immune disorders.
            Since stem cells have the potential to be of ever increasing importance to medical care, albeit not for a few years, it is important to understand just what a stem cell is, generally how the various types of stem cells differ from each other and how they are either found in the body or produced in the laboratory. The key characteristics of stem cells are that 1) they can replicate themselves and 2) they can become mature cells that make up the tissue and organs of the body.
Embryonic stem cells are found in the earliest divisions of the fertilized ovum and can become any of the body’s approximately 200 types of cells (liver, lung, brain) and they have the capacity when placed in tissue culture in the laboratory to divide and to replicate themselves indefinitely. We call them pluripotent in that they can become any of the various types of cells in the body. Think of them as the most fundamental cellular building block that can create the tissues and organs of our body.
            Adult stem cells, as the name implies, can be found in the bodies of adults (or newborns and children for that matter.) They also can self replicate but when placed in tissue culture it has not been possible to have them replicate indefinitely as embryonic stem cells do. Adult stem cells generally only can differentiate into one type of the body’s cells or tissue, i.e., are unipotent. For example muscle stem cells only become muscle cells but not liver cells. But some adult stem cells, such as those from the bone marrow, can become multiple but not all types of cells. Stem cells obtained from the umbilical cord of a newborn baby are more like adult stem cells in that they can develop into some but apparently not all cells types. In effect, they are further along in the chain of differentiation.
There are also other types of stem cells that as of now are being produced in the laboratory and which have many of the attributes of embryonic stem cells – nuclear transfer, induced pluripotent, and protein-induced pluripotent stem cells, among others. To create the nuclear transfer stem cell, an unfertilized egg is obtained from a woman’s ovary. The egg has its nucleus extracted by a micropipette and then has the nucleus of an adult cell inserted in its place. This nucleus might be obtained from a skin cell taken from the arm of a patient with a particular problem such as diabetes. The newly created cell is placed in culture and with the appropriate signals begins to act like an embryonic stem cell in that it will divide and replicate itself and with the appropriate signals the daughter cells can become various body cell types. The hope is that these cells, genetically identical to the patient who had the skin biopsy, could be grown up into a vast number of – in this example – pancreatic islet cells and used to treat this individual patient’s diabetes. 
The induced pluripotent stem cell (or iPSC) also has many of the embryonic stem cells’ characteristics. It is produced by taking a person’s cells such as from the skin of the arm and then stimulating them by inserting a few key genes, using a retrovirus. These genes reprogram the cell to revert to what is similar to an embryonic stem cell. The concern of course is that it is induced using a virus. More recent experiments have found that certain proteins can reprogram the cell just as can the virally-inserted genes. These stem cells are known as protein-induced pluripotent stem cells (piPSC). Both are being evaluated to determine if they can be as effective as embryonic stem cells. With each of these three techniques, a clear hoped for advantage is that a person can donate his or her own cells for transformation into stem cells and from there into whatever cell is of interest, such as pancreatic islet cells that secrete insulin. Such cells transplanted back into the person would be recognized as “self” and not trigger rejection with a graft vs. host response by the body. This concept with each technique is therefore all about “personalized medicine.” 

Next time I will delve more deeply into adult stem cells followed the next time by embryonic stem cells. But in the meanwhile think of stem cell science as one more of those truly transformative medical megatrends that will revolutionize the practice of medicine in the years to come and in the process improve the healthcare of you and your family.

Wednesday, July 4, 2012

Antibiotic Resistant Bacteria Are A Major Threat – Preventing Transmission is Critical

Imagine a person that develops an acute problem that requires hospitalization and even a time in the ICU. Serious but something that modern medical care can deal with and cure. Until …the patient now develops an unexpected serious infection and despite excellent and appropriate medical care, dies. Unfortunately this scenario is all too common in today’s hospitals. 

More than 100,000 Americans die each year from hospital acquired infections; that is the infection developed only after admission to the hospital.  Many more develop and yet the patient survives.  The cost to the healthcare system is immense – $6 to 7 billion per year!  Many are caused by bacteria that are resistant to our most important antibiotics.  So prevention is critical.   

The antibiotic resistant bacteria are not new news but we often don’t appreciate how serious the problem really can be.  The use of new antibiotics, especially very broad spectrum antibiotics, creates the setting for a resistant bacteria to multiply and a healthcare setting like a hospital or a long term care facility (LTCF) creates the chance for patient to patient transmission.

Some bacteria like “staph” (Staphylococcus aureus) have become resistant to the most effective agents, especially penicillin derivatives such as methicillin and hence the term we are familiar with called methicillin resistant Staphylococcus aureus or MRSA.  At least one drug, vancomycin, is usually still effective although it must be administered intravenously.   

Another problem is what’s known as “carbapenem-resistant Klebsiella pneumoniae” (CRKP).  These bacteria have become rather frequent causes of serious hospital acquired infections.  Carbapenems are very powerful antibiotics developed to treat gram negative bacteria like this one.  But resistance has developed and when it occurs the resistance is usually to essentially all antibiotics, not just the carbapenems. 

Without a means of therapy, the key is to prevent transmission and hence infection.  Hand washing and the use of antibacterial lotions are critical.  Approaches to reduce contact are important as well.  Extensive disinfection of rooms and equipment is a must.  And avoiding antibiotics unless truly necessary is essential.  There are other critical steps related to each of the common sites of infections – IV line infections, pneumonias, urinary tract infections, post-operative wound infections, etc. Adherence to check lists of evidence-based prevention protocols are key.  

The hands of providers are a major route of transmission. Hand washing and antibacterial lotions work but only if used. Hospitals need to enforce the rules and put sanctions that have meaningful teeth in place (such as exclusion fromr the OR or not able to admit patients for a week for the observed second offense -- both of which are economic sanctions that get the providers’ attention.) Isolation procedures with gloves, mask, gown and booties are needed in some situations to prevent transmission from room to room, patient to patient.  

Even extensive attempts at disinfecting the patients rooms (or ICU cubicle, OR or procedure room) may not be adequate, leaving viable organisms behind. Newer approaches such as room misting with binary ionization of low strength hydrogen peroxide (StereaMist) when used according to protocol can effectively destroy all bacteria, fungi and viruses plus spores such as C difficle. The process is fast (less than ten minutes per room), the material kills on contact, converts to oxygen and water, and the room is immediately ready for the next patient. SteraMist is relatively new so this is not an endorsement but it may be worth considering for further due diligence. (Disclosure – I have gotten to know the company, Tomi Environmental Solutions, through some consulting) 

Many hospitals now have antibiotic “stewardship” programs designed to assure that broad spectrum antibiotics are used only when absolutely indicated, are discontinued as soon as possible, and are converted to narrower spectrum agents once the causative bacteria is defined. These programs are effective at reducing the use of these agents, thereby reducing the opportunity for resistant organisms to spread and infect patients and have the side benefit of reducing costs quite substantially. 

One major issue, often not appreciated, is that patients arrive at the hospital already colonized with resistant bacteria.  Residents of long term care facilities (LYCF) are often colonized in part because the individuals may have picked up the bacteria during a recent hospitalization.  And spread from person to person in the LTCF setting is relatively commonplace – what with multiple occupancy rooms and common dining and activity areas.  Some LTCF residents often have multiple medical conditions and so they are more susceptible than others to having an infection develop, sending them back to the hospital.  A sort of vicious cycle is compounded by various underlying chronic illnesses that render the resident more susceptible to infection. 

Hospital acquired infections cause many deaths and much suffering in addition to substantially adding to the costs of care. The rise of antibiotic resistant bacteria has now reached critical importance.  With few or no antibiotics available now nor on the horizon to treat infected patients, preventing transmission is absolutely essential.  This is a lot easier said than done but it can be done and there is no excuse for not doing so. 

Post Script: My new book, The Future of Healthcare Delivery – Why It Must Change and How It Will Affect You, has a chapter that discusses this issue in more detail.  See www.medicalmegatrends.com for more information. 

Friday, June 15, 2012

Can You Get a Prompt Appointment With Your Doctor?

Having trouble getting an early appointment with a doctor? It’s a common problem. Here is one company’s proposed solution.

It takes an average of 20.5 days to get an appointment with a physician, according to a study by Merritt Hawkins & Associates and related to me by the principals at ZocDoc, a startup company. That’s a long time. ZocDoc aims to fix that problem with a rapid appointment scheduled on line.

Perhaps your need is not urgent in the classical sense but imagine you were just told your mammogram was suspicious and that you should see a surgeon for a biopsy. Waiting three weeks just to be seen (plus another wait for the scheduled biopsy date) will seem like a lifetime of anxiety,  but a company called ZocDoc has set out to improve patients’ access to care by making the market for doctors’ appointments more efficient, to the benefit of patients and doctors alike.

But if the doctor is booked up what can you do except wait it out? It turns out that physicians have a 10-20% cancellation rate. Maybe someone’s serious problem got better on its own. Maybe they went to the ER instead of waiting. Or maybe he or she just forgot because the appointment was made so long ago. For whatever reason, the doctor has many last minute openings; but you don’t know about them.

Cancellations mean no income for that time slot, but the physician’s fixed costs of office rent, staffing, insurance, etc. don’t go away. So he or she would like to fill those empty time slots if possible. 

In response, ZocDoc has created a software system that works with physician’s scheduling systems. Basically, patients go online and insert the particular type of physician they need to see (e.g., primary care, ENT, dermatologist, etc.) as well as their location. ZocDoc scans the real-time schedules of the physicians meeting that search criteria and allows patients to instantly book an appointment online. ZocDoc tells me that 40% see a doctor within 24 hours and 60% will be seen within 72 hours. And, although ZocDoc does not presently put you on a waiting list, you can always check back on ZocDoc and see if an earlier time slot becomes available.

My only concern is that you as a patient are best served with a single primary care physician (PCP) with whom you have a long standing personal relationship. He or she knows you, your medical status and the issues of work and family. Going to a different PCP for a one time problem is not the best medicine – although I would agree that it is far superior to a long wait in the emergency room.

The specialist situation is somewhat different however. Usually, your PCP is the best person to make a referral. As your advocate, the PCP wants you to be well served with quality care and so will generally refer you to a specialist that the PCP knows by years of personal experience is not only competent but respectful of patients. And if the PCP is really on your side, he or she will personally call the specialist, explain the reason for the referral and, when appropriate, ask for an early appointment.

But if you can’t get to your PCP for many days and you just fell and have a swollen ankle, ZocDoc could presumably get you into an orthopedist’s office quickly. Or to a surgeon for that breast biopsy. Getting to see that orthopedist or surgeon in one to three days rather than three weeks would be a godsend – getting appropriate therapy for the sprained ankle or just relieving three weeks of anxiety waiting for a biopsy. 

ZocDoc appears to be at first glance a game changing approach. If they are correct it will make a major transformation in the delivery of medical care. It will be interesting to watch ZocDoc and see how it evolves.

Notes – ZocDoc was noted in a Wall Street Journal article today on innovation. I have no financial relationship with ZocDoc; I learned about it serendipitously. There is more about the delivery of health care in my new book The Future of Health Care Delivery-Why It Must Change and How It Will Affect You.

Tuesday, June 12, 2012

Integrative Medicine Part V - Busting Stress

Stress is with us all the time. Issues at work or at home, getting a traffic ticket, the grocery store out of your favorite yogurt. Life has stresses. We can go to the doctor and ask for a pill or we can learn to deal with our stresses effectively without much medication. 

Acute stress is normal and can even be lifesaving – seeing a truck barreling down the road at us. But when stress is chronic it becomes a major cause of ill health.  

Chronic stress builds up when the demands upon us become greater than our resources to respond in an effective manner. Stress tends to become cumulative. You can handle the first stressor and even the second, but when the third one occurs, even if it was rather minor, it tips over your balance point. Since we cannot completely escape stress, our agenda must be to boost our resources – to “fill up our cup” as Delia Chiaramonte, MD of the University of Maryland Center for Integrative Medicine liked to term it during her “Busting Stress” workshop at the Center’s recent Health and Wellness Conference held in Baltimore, MD.  

Integrative medicine does not avoid traditional “western” medical approaches such as medications. But it does look at the whole person to determine if there are other parts to the “prescription” that might be equally or even more valuable. The agenda is to maintain health and further develop wellness.

There are external and internal sources of stress. Our boss ignored our hard work or disparaged our report – these are obvious external stresses. If they become too much it may be best to just look elsewhere for a new job and escape the situation.  

But other stresses are internally mediated. We might convert an event into a thought that in turn leads to a negative feeling that in turn causes stress. Imagine that a loved one is late to get home and has not called. That is the event. The thoughts can be quite different. One thought might be that he was in an accident resulting in a stressful feeling of anxiety. Or perhaps this event leads to the thought that he is having an affair – leading to a feeling of hurt. Or perhaps the thought is that he just didn’t care that he was late and didn’t bother to call – leading to a feeling of anger. Perhaps more likely he is just stuck in bad traffic and doesn’t have his cell phone with him – in that case you might have a feeling compassion. The three stressful feelings came from your thought interpretation of the event. The question you need to ask yourself is what is the likelihood of any of these thoughts being correct?  

You need to restore rationale thinking. Do this by labeling the irrational thought and then refute it with a new thought like “I have no evidence of an accident; he is probably just stuck in traffic.” Then detach yourself from the thought with the recognition that “this is an anxious thought, not a rational thought.” Finally, do something to distract yourself like playing with the kids.

To “fill up your cup” Dr Chiaramonte suggests considering these approaches. Begin a “gratitude ritual.” This means to take a time each day for gratitude perhaps while falling asleep or perhaps at dinner time. Think about what is good in life – today – maybe a spring flower, a smile from your loved one, the bright eyes of your child. It can’t be a rote thought however. Make it different every day. Amazingly enough, it works. It will increase your happiness and correlates well with general health and well being. 

Here is a line from the song “Counting My Blessings” sung by Bing Crosby and Rosemary Clooney in the movie “White Christmas.” "When my bank roll is gettin' small, I think of when I had none at all, and I fall asleep counting my blessings..." This is the concept of gratitude. 

A second approach is to aggressively try to be a “benefit finder” rather than a “fault finder.” It’s an approach in which you rethink and with doing so decrease your emotional reactions. Instead of the thought, “I have a vision problem that limits me” you might instead think of, “I still have one good eye and the world looks good to me.” 

Sleep is important. You feel more stressed if you are sleep deprived. Most of us get too little sleep. Fill your resource cup with added sleep. And the gratitude ritual at bed time will help you sleep more soundly.  

Food is equally as important. Things to avoid are processed foods with high levels of carbohydrates and fats (of course, these are the ones that taste so good to us!) like doughnuts, macaroni and cheese or pizza. Instead get more high quality proteins and skip the refined sugars as in sodas.  

And add in some exercise. Just moderately paced walking each day will not only decrease your stress but will improve your cardiovascular health, bone health and overall add to your sense of wellness.  

This may sound like a lot of effort. Actually it’s really not. It doesn’t take much time; it improves your physical health; and it will allow you to cope much better with stress. Better to “fill your cup” than rely on an anti-anxiety medication. 

Note: You can find the Center for Integrative Medicine on Facebook at http://on.fb.me/HWRPKp . And you can learn more about improving your health while reducing your costs in my book The Future of Health Care Delivery- Why It Must Change and How It Will Affect You

Tuesday, May 29, 2012

Integrative Medicine Part IV - Preventive Aging

Does old age necessarily mean declining health and cognition or can one age gracefully with a high quality of life?  

This was another topic discussed at the recent Health and Wellness conference organized by the University of Maryland Center for Integrative Medicine.  Steven Gambert, MD, Professor of Medicine and Surgery and Director of Geriatric Medicine at the University of Maryland Medical Center described preventive aging. Here are my notes from his talk with some personal observations added in. 

America has a rapidly aging population. In 1900 only 4% were over age 65 and 1% over 75 years. By 1950, it was 8% and 2.6% respectively and by 2000 it was 13% and 5% with these expected to grow to 21% and 8% by 2030. In absolute numbers, there are now about 12 million over the age of 80; a doubling since 1957. Older people run the full gamut from the very healthy, to those with a few health issues, to those with multiple problems to the very frail. Frail individuals (see my earlier post of frailty) have a high risk for poor outcomes of any illness, slower recovery and heightened mortality. So the agenda, of course, is to stay as healthy as possible throughout your later years.

Can you do anything to prevent illness? Can you embark on a “preventive aging program?” The answer is definitively “yes” and it is never too late to get started. But just like saving up for retirement, it’s best to begin at an early age so that the value can compound through the years.  

The first major element of the preventive aging program is to prevent an acceleration of the normal aging process. Most physiologic functions begin a slow but steady decline beginning at about age 30 to 35. This includes our bone density, kidney and lung function and cognitive skills. Some decline is inevitable but the process can be slowed. There are four basic steps.  

In no particular order the first step is to avoid environmental risk. It is never too late to stop smoking and so reduce the risk of lung cancer and other cancers but also to slow the decline of general lung function. Noise is an environmental hazard. Hearing declines with age and noise rapidly accelerates that decline. Loud music and loud restaurants are best avoided despite our current cultural attractions to both.  

The second step is proper nutrition. Eating foods with a wide mix of vitamins and minerals, high quality protein in sufficient quantity, good oils and fats and lots of fiber is of critical importance. Vitamin and mineral supplements are still valuable but they should be just that – supplements – not the prime source.  

The third step is exercise. Our muscles were meant to be used and we need to do just that. A regular regimen of moderate aerobic exercise such as walking for 30 minutes each day can’t be beat. Add to that some weight bearing exercise (probably at a gym or similar facility) three times each week to maintain and build strength. And remember to do both range of motion such as simple stretching or adding in yoga and balance exercises regularly.  

The fourth and very critical step to prevent acceleration of normal aging is to exercise your brain. Do some activities that challenge your mind – Sudoku or chess does that; watching TV definitely does not!  

Following these four steps can dramatically slow the aging process but you next need to prevent age prevalent diseases. Here again the best time to do this begins when you are young. The leading causes of death in the elderly are heart disease, cancer and stroke – no surprise here. Each of these are largely but not entirely preventable by attending to our lifestyles. Unfortunately most Americans eat a non-nutritious diet and too much of it, don’t get enough exercise, are chronically stressed and 20% smoke. The result is a population which is obese, with high blood pressure, an actual developing epidemic of diabetes and over time a high incidence of heart disease, cancer and stroke. So it behooves us to address our lifestyles beginning at whatever age we may be today and following though over the years.  

In addition older people should be sure that their immunizations are up-to-date such as annual influenza in addition to the pneumonia vaccine and shingles vaccine but also the less commonly paid attention ones such as tetanus and diphtheria. And as already suggested, avoid high noise environments, eat a good diet, get regular exercise and use your brain regularly.  

Part of healthy living includes adequate sleep. It’s simply not true that older people need less sleep. It is true that older people don’t sleep as well or as soundly and may need naps.  

Stress reduction (see a later post in this series for more information) in this hectic world is equally important. Seek ways to reduce this burden with tools such as meditation, mindfulness training, yoga, etc. Exercise can in itself be a great way to reduce stress and may have an impact on our own endogenous neurotransmitters to alleviate stress. 

Finally healthy aging also requires social contact. A good social life is actually critical to healthy aging. It will “add life to your years.”  

Aging gracefully is discussed in more detail in the last chapter of my book The Future of Health Care Delivery – Why It Must Change and How It Will Affect You. 

So it is possible to age gracefully with good health. Starting the process when you’re young makes it all that much more effective. But it is never too late to get started. It’s possible to just die of “old age” rather than one of the common chronic illnesses that are today’s plagues.  

Note: You can find the Center for Integrative Medicine on Facebook at http://on.fb.me/HWRPKp

Sunday, May 20, 2012

Integrative Medicine Part III - Humanism In Medical Care

Have you ever thought that the doctor wasn’t listening to you? Didn’t seem to understand what was important to you? Was talking in medical speak but not in a language you could understand? That he or she gave bad news to you and left you hanging as to what to do next? Unfortunately, these are all too common.  

Medical advances such as new drugs, imaging devices, operating room technology and others are coming rapidly and greatly expanding what can be done for patients. But concurrently it also seems to many that medicine is so technologically focused that the age old art of humanism has become a legend. What the doctor needs to remember is that you are a human with the needs of a human; the doctor needs humanism. 

The University of Maryland Center for Integrative Medicine hosted a “Health and Wellness Conference” recently to celebrate the Center’s 20th anniversary. One plenary session was given by Thomas Scalea, MD, professor and director of the R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center in Baltimore. The Shock Trauma Center is arguably the best trauma center in the country if not the world. It admits only those 3-5% of trauma patients with the most extensive injury yet survival consistently exceeds 95-97%. Credit this to the State’s emergency transportation system and the Shock Trauma Center’s exquisite teamwork, the well trained staff and the best of technology. As Dr. Scalea noted, the Shock Trauma Center is perhaps the zenith of technologic prowess.  

But, he reminded the audience that the patient also needs the provider to be humanistic. He gave some examples. Here are some that I remember from his talk, sprinkled occasionally with my own thoughts.

When you enter the room, sit down and talk with your patient. Be at their eye level, not an imposing figure hovering over the bed. 

Speak to the patient in clear English; not in medical speak. Medical speak is for your convenience and is a way of obfuscating but not communicating.  

Expect to repeat what you say tomorrow and again the next day again; your patient needs to hear it repeatedly. Don’t be annoyed they forgot it all by tomorrow morning.   

If you have bad news to deliver hold the patient’s hand. Touch has a lot of power. I would add here, when you must give bad news, be clear. The patient has already guessed his situation so don’t try to avoid the truth and be sure to then immediately explain what you propose as next steps. As a medical oncologist, I learned that this was absolutely essential. Don’t let this part wait for another day. Your patient needs to hear it right now so they can begin to focus not just on the bad news but on the hope of a new treatment or whatever plans you propose for the future, even if that means hospice. 

When you visit your patient don’t just talk, listen. Listen hard and long. Dr. Scalea described a trainee getting behind him and looking across his shoulder at the patient. When Dr. Scalea asked why he took that position, the resident responded that he wanted to see what Dr. Scalea saw. “I’m not looking, I’m listening” was the answer. Of course, “listening” also includes observing the patient’s body language including facial movements. 

Be sure what you tell the patient or family is clear. It needs to be in direct every day speech. He told of going to tell a mother that her son had died. The resident who had been working with him asked if he could be the one to deliver the bad news. “Sure, I’ll just sit to the side.” The resident used a lot of words about how injured her son had been, how they had tried to save him in the operating room, etc. and then  stood up to leave. “Wait,” said Dr. Scalea. He went over, sat down, and holding her two hands said, “Do you realize that your son has died?” She had not. It is critical to be clear. 

He described a scene at a famous hospital. The world renowned doctor and his retinue came into the patient’s room. He explained to the man that he needed a heart valve replacement. The patient thanked him and said he needed to talk to his doctor before agreeing to the surgery. The expert was clearly annoyed that his word was not sufficient. “What is your doctor’s name?”  “Dr. Hamilton.” “What is his phone number?” “I don’t know.” “Well how can I call him?” the physician sort of growled. “Well he’s right here in the room – right over there.” He was the third year medical student, the only one on the team that until now had taken the time to really talk to the patient. The expert and his retinue left. The student remained behind. The surgery was soon scheduled for the next day.  

Finally I would add that being a doctor is a privilege. We are given that privilege as a result of our medical school and residency training and our willingness to put patient care above everything else. It is a special privilege. We need to always remember that it is a privilege given to us by the patient – each and every time we have an encounter. It is a privilege that the patient can chose to retract. 

Note: You can find the Center for Integrative Medicine on Facebook at http://on.fb.me/HWRPKp . There is more about the delivery of health care in my new book The Future of Health Care Delivery-Why It Must Change and How It Will Affect You.

Monday, May 14, 2012

Integrative Medicine Part II -- Health Care of the Future

Is it possible that health care can become more effective, more personalized, more attuned to real health and wellness in a manner that truly benefits you the customer?  

At the recent health and wellness conference celebrating the 20th anniversary of the University of Maryland Center for Integrative Medicine there was a panel discussion moderated by Center director Brian Berman, MD on the topic of health care of the future. Here are some excerpts from the comments made by Dr. Delia Chiaramonte, Dr. Jeff Bland and myself.  

The first question was what are the problems with the health care system today? Here are some of the responses:

There is excellent research and innovation along with superb providers in this country. But the delivery system is dysfunctional and to date America has tolerated this dysfunction. It’s a medical care not a health care system. The emphasis is strongly on disease management and not disease prevention or health promotion. American medical care is very expensive, about $8,000 per capita and yet outcomes are not what they could or should be. For example, America does not have the lowest infant mortality rate nor the longest life span. Other developed countries beat us on both counts. Medical care of acute illness is generally quite good in the United States but chronic diseases – of which there are more and more occurring – are not well cared for. The system is provider oriented rather than patient oriented and the patient is not the real customer.  

There is a shortage of primary care physicians and this is getting worse every year. Only 30% of American physicians are primary care physicians compared to about 70% in most other developed countries. Those still in primary care practice have inadequate understanding of the causes and prevention of chronic diseases. And too few appreciate the importance of care coordination nor the full range of non-pharmacologic options for care.  

The second question was what can patients do to get the best possible health care? Among the responses, here are a few:

Since today the patient is largely not the customer of the doctor, a good place to start is to change that paradigm. A high deductible health policy means that the patient will now be paying the primary care physician directly for care and thus this changes the professional-client relationship to a more normal occurrence. The physician will now become more attentive, allocate more time, offer more preventive care and will coordinate the care of chronic illnesses.  

Individuals also need to take more responsibility for their health and wellness directly. Attention to nutrition, exercise, stress and tobacco are key first steps. Work place wellness programs can materially assist. They can offer a health care premium deduction in return for engaging in added educational programs to improve lifestyles. 

Social networking can have an increasingly beneficial effect. Lifestyle changes are easier to accomplish in a peer group setting. Usually we think of this as a physical group setting but it can also be done through the use of social media. Groups help give a positive reinforcement for behavior change.  

Social networking through sites such as Facebook, Twitter or You Tube or others can be used to leverage the medical care delivery system to become more patient centered, more effective at the coordination of chronic illness, more attuned to prevention and responsive to true integrated medicine.

Everyone should have a primary care physician, one well schooled in the most current evidence-based care approaches yet who is attuned to the full gamut of integrative medical approaches such as chiropractic, nutrition, personal training, massage therapy, and acupuncture. You need to be sure that your primary care physician will spend the time needed to deal with health and wellness and not just disease. You may well need to pay your primary care physician directly rather than buy insurance but the primary care physician will then be financially able to offer you the time you really need and deserve.  

The third question was what will the health care provider of the future be like and how will integrative medicine contribute to health care in the future?

This question was addressed in an earlier post; go to this link.     

You deserve superb integrative health care but to get it you will need to take some action to obtain it. Call it a balancing of rights with responsibilites. It may cost you dreictly rather than via insurance but you may well find that the return on investment is well worth it. You can find much more discussion of this topic in The Future of Health Care Delivery – Why It Must Change and How It Will Affect You. 

Note: You can find the Center for Integrative Medicine on Facebook at http://on.fb.me/HWRPKp

Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).